Harmony Patient Information Form

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Place the
Ordering Lab
PAT barcode
Specimen ID
label here
1
2
Patient Information
Clinic Information
First Name
Clinic Name
Last Name
Ordering Clinician
Street Address
Street Address
City
Province
City
Province
Country
Postal Code
Country
Postal Code
Phone:
Phone
Fax
Gender
Female
Male
Health Insurance Number
Weight (kg)
Height (cm)
3
Patient Consent
I hereby authorize Dynacare or its designate to collect a biological specimen from me or from an individual for whom I have the legal
right to authorize the collection and testing of a specimen. I further authorize Dynacare or its designate to perform testing on that
specimen. I have received sufficient information about the Harmony Prenatal Test and have received satisfactory answers to my
questions. I understand that therapeutic decisions should not be based solely on the results of prenatal screening. I understand that my
sample will be sent to a laboratory in the United States for testing. I understand that personal information, including but not limited to
name and date of birth, will accompany the sample. Personal information held in countries outside of Canada could be subject to
disclosure to government or other authorities (whether of that country or of another country).
Year
Month
Day
Patient Signature
4
Clinician Signature
I attest that this patient has been informed about details of the test and its capabilities and limitations, and has given consent for this
test.
Year
Month
Day
Clinician Signature
5
Required Test Information
 Harmony Prenatal Test
Year
Month
Day
Year
Month
Day
 with Y Analysis*
Draw
Is this a
 Yes
Patient’s
 with X,Y Analysis*
Date
redraw?
 No
Birthdate
* Singletons only
Year
Month
Day
Gestational
Measured
________weeks ________days
by:  U/S  LMP  IVF
Age
on
Year
Month
Day
LMP Date
Egg
Age at
# of Fetuses
 1
 2
IVF Pregnancy
 Yes
 No
 Self
 Non-self
Donor is
retrieval: __________ years
888.988.1888
3885, boul. Industriel
Laval (QC)
Canada H7L 4S3
F 450.663.4428
TP-00056-F9 Rev 1.0 Effective Date: 11/19/2013

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